Utilization and Quality Management

NIA is compliant with state and national requirements when performing utilization reviews or managing quality of care issues. Currently there are a number of accrediting agencies that set standards for the review of patient records, the qualifications of the reviewer, the policies and procedures that must be in place for appropriate reviews, and the remedies available to a member if they do not agree with the outcome of a review. NIA follows standards that have been established by NCQA (National Committee for Quality Assurance)  and the Department of Labor, as well as state and federal guidelines. Abiding by specific standards not only ensures that we offer a fair and consistent review of services, but also that we meet required guidelines for reporting results of reviews to the member, provider, and health plan. NIA maintains specific documentation regarding the review, complaint and appeal processes. We are also bound by strict timelines for the handling of any issues. Such processes are subject to annual review by our Quality Management Committee and must meet national standards.  

Quality improvement and compliance standards enable NIA to promptly and consistently manage any complaints that might arise due to quality of care issues. These same standards compel us to review ways in which we can positively impact the quality of care provided to members by utilizing an Annual Work Plan initiative. Our current plan is intended to improve patient-provider communication, implement consistent use of active treatment, and advance patient education.